ENT Coding
description
Transcript of ENT Coding
ENT CodingPresented by Lori Dafoe, CPC
AGENDA:Click icon to add picture• Review 2013 Coding
Changes specific to ENT
• Review the sinuses anatomy
• Discern medical necessity for various sinus procedures
• Identify endoscopic sinus procedures
• Review the CPT coding and guidelines
New Codes for 2013 – Allergy TestingAllergy Testing: CPT codes 95010 and 95015 have been deleted. To report, use the two new codes below.
•95017 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with venoms, immediate type reaction, including test interpretation and report, specify number of tests
•95018 Allergy testing, any combination of percutaneous (scratch, puncture, prick) and intracutaneous (intradermal), sequential and incremental, with drugs or biologicals, immediate type reaction, including test interpretation and report, specify number of tests
New codes for 2013 - Ingestion Challenge TestingIngestion Challenge Testing: CPT 95075 has been deleted and two new codes have been created to report ingestion challenge testing.
•95076 Ingestion challenge test (sequential and incremental ingestion of test items, eg, food, drug or other substance); initial 120 minutes of testing
•+95079 each additional 60 minutes of testing (List separately in addition to code for primary procedure)
Additional new codes for 2013• 2 new codes to report pediatric polysomnography for
children under the age of 6. These services will be reported using new CPT codes 95782 and 95783.
• 2 new codes to report intraoperative neurophysiology monitoring in the operating room. This includes new introductory language in that section of the CPT book as well. These services will be reported using new CPT codes 95940 and G0453.
Anatomy of the Facial Sinuses Nasal septum Ethmoid (right and
left) Maxillary sinus
(right and left) Turbinates (concha)
Superior Middle Inferior
Upper Respiratory System
Nasal Cavities
Perinasal Sinuses
Medical Necessity Nasal polyps or mucoceles
Chronic sinusitis
Tumors of the nasal and sinus cavities
Recurrent sinus infections or complications of sinusitis
Nasal Polyps
Medical Necessity Cerebrospinal fluid leaks
Juvenile Angiofibroma
Nasolacrimal duct obstruction
Choanal Atresia
Chronic sinus headaches
Medical Necessity Typically, patients should have used
medical therapies first, with no significant signs of improvement, before sinus surgery is performed.
The Procedure An endoscope is an instrument made up of a camera
mounted on a flexible tube.
This can be inserted into small anatomical sites, such as the nose and mouth to visualize the internal aspects of the body.
Nasal/Sinus Endoscopy - Anatomy
The Procedure Small attachments can
Take biopsies of suspicious tissues through the endoscope
Perform excisions
Or other needed functions
The Procedure Endoscopic Sinus Surgery can be
performed under either
Local anesthesia or
General anesthesia
The Procedure Sometimes sinus surgery may require
simultaneous repair of the nasal septum
The use of packing will depend on the extent of surgery and physician preference
Coding Endoscopy CPT 31231-31294
Nasal/Sinus Endoscopy
Unilateral procedures (unless specifically noted in the code description as bilateral)
Coding Nasal Endoscopies Diagnostic
Procedures
Diagnostic Evaluation CPT 31231-31235
Nasal/sinus endoscopy for the inspection of: Interior nasal cavity Middle and superior meatus Turbinates Spheno-ethmoid recess
Diagnostic Evaluation All diagnostic evaluations include all of
these areas
Do NOT code each area separately!
Diagnostic Evaluation 31231 Nasal endoscopy,
diagnostic,unilateral or bilateral (separate procedure)
31233 Nasal/sinus endoscopy,diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)
31235 Nasal/sinus endscopy, diagnostic with sphenoid sinusoscopy (via puncture of spendoidal face or cannulation of ostium)
Identify Access Point
Coding ScenarioA patient, diagnosed with chronic sinusitis, told his physician that no medication has worked and the inflammation just won’t go away. The doctor ordered a diagnostic endoscopy via the inferior meatus, with a maxillary sinuscopy.
What is the most accurate CPT code?1.) 312312.) 312333.) 31235
31231 Nasal endoscopy, diagnostic,unilateral or bilateral (separate procedure)
31233 Nasal/sinus endoscopy,diagnostic with maxillary sinusoscopy (via inferior meatus or canine fossa puncture)
31235 Nasal/sinus endscopy, diagnostic with sphenoid sinusoscopy (via puncture of spendoidal face or cannulation of ostium)
Nasal/Sinus Endoscopic Surgical Procedures CPT 31237-31294
Nasal/sinus endoscopy, surgical
Surgical sinus endoscopy includes: Sinusotomy (as appropriate) Diagnostic endoscopy
Coding Functional Endoscopic Sinus Surgery (FESS) 31237 Nasal/sinus endoscopy, surgical;
with biopsy, polypectomy or debridement
31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage
CPT 31239 Nasal/sinus endoscopy, surgical; with dacryocystorhinostomy
Performed when the nasolacrimal duct is blocked and the flow of tears needs to be restored through the creation of a new tear duct canal
31240 Nasal/sinus endoscopy, surgical; with concha bullosa resection
31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
31255 Nasal/sinus endoscopy, surgical; with ethmoidectomy, total (anterior and posterior)
Surgical Endoscopy, cont.
31256 Nasal/sinus endoscopy, surgical, with maxillary antrostomy
31267 Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus
http://www.youtube.com/watch?v=lrX8gAJfiJs
31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus
31287 Nasal/sinus endoscopy, surgical, with sphenoidotomy
31288 Nasal/sinus endoscopy, surgical, with sphenoidotomy; with removal of tissue from the sphenoid sinus
Nasal/sinus endoscopy, surgical, with repair of cerebrospinal fluid leak;
31290 …ethmoid region 31291 …sphenoid region
Nasal/sinus endoscopy, surgical;
31292 …with medial or inferior orbital wall decompression
31293 …with medial orbital wall and inferior orbital wall decompression
31294 …with optic nerve decompression
Coding ScenarioThe doctor performed a nasal endoscopy to control chronic epistaxis. What is the correct code?1.) 312382.) 312543.) 31276
31238 Nasal/sinus endoscopy, surgical; with control of nasal hemorrhage
31254 Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior)
31276 Nasal/sinus endoscopy, surgical with frontal sinus exploration, with or without removal of tissue from frontal sinus
Balloon Sinus Dilation http://
sinussurgeryoptions.com/sinusitis-treatments/balloon-sinus-dilation
Coding Balloon Dilation 31295 Nasal/sinus endoscopy, surgical; with dilation of
maxillary sinus ostium (eg, balloon dilation), transnasal or via canine fossa (Do not report 31295 in conjunction with 31233, 31256, 31267 when performed on the same sinus)
31296 with dilation of frontal sinus ostium (eg, balloon dilation) (Do not report 31296 in conjunction with 31276 when performed on the same sinus)
31297 with dilation of sphenoid sinus ostium (eg, balloon dilation) (Do not report 31297 in conjunction with 31235, 31287, 31288 when performed on the same sinus)
CPT 69210 – Removal impacted cerumen, 1 or both ears (separate procedure)
CPT Assistant July 2005, page 14 - Auditory System, 69210 (Q&A)
In collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), we present the following discussion which provides some typical coding scenarios with regard to the appropriate use and application of CPT codes related to ear wax removal:
1.The patient presents to the office for the removal of “ear wax” by the nurse via irrigation or lavage.
2.The patient presents to the office for the removal of “ear wax” by the primary care physician via irrigation or lavage.
3.The patient presents to the office for “ear wax” removal as the presenting complaint. This is described as impacted cerumen because it completely covers the eardrum and the patient has hearing loss. The impacted cerumen is removed by the primary care physician or otolaryngologist with magnification provided by an otoscope or operating microscope and instruments such as wax curettes, forceps, and suction.
QuestionAre these procedures appropriately reported with CPT code 69210, Removal impacted cerumen (separate procedure), one or both ears?
AMA CommentA major element in determining whether code 69210 should be reported is understanding the definition of impacted cerumen. By definition of the AAO-HNS, “If any one or more of the following are present, cerumen should be considered ‘impacted’ clinically:
•Visual considerations: Cerumen impairs exam of clinically significant portions of the external auditory canal, tympanic membrane, or middle ear condition.•Qualitative considerations: Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching, hearing loss, etc.•Inflammatory considerations: Associated with foul odor, infection, or dermatitis.•Quantitative considerations: Obstructive, copious cerumen that cannot be removed without magnification and multiple instrumentations requiring physician skills.”
Other issues may also require consideration. Removing wax that is not impacted does not warrant the reporting of CPT code 69210. Rather, that work would appropriately be captured by an evaluation and management (E/M) code regardless of how it is removed. If, however, the wax is truly impacted, then its removal should be reported with 69210 if performed by a physician using at minimum an otoscope and instruments such as wax curettes or, in the case of many otolaryngologists, with an operating microscope and suction plus specific ear instruments (eg, cup forceps, right angles). Accompanying documentation should indicate the time, effort, and equipment required to provide the service. Add-on code 69990, Microsurgical techniques, requiring use of operating microscope (List separately in addition to code for primary procedure), should not be reported if the operating microscope is used for cerumen removal. In this later instance, however, code 92504, Binocular microscopy (separate diagnostic procedure), may be reported.
Therefore, based on this information, scenarios 1 and 2 would not be reported with code 69210. These scenarios would be captured by the appropriate E/M code. Scenario 3, however, should be reported with code 69210 because both criteria were met; the patient had cerumen impaction and the removal required physician work using at least an otoscope and instrumentation rather than simple lavage.
HCPC - G0268 Removal of impacted cerumen (one or both ears) by physician on same date of service as audiologic function testing
• Must be billed by a physician, physician assistant, or nurse practitioner. Cannot be billed by an audiologist!
RACS are here!! The Recovery Audit Contractors are
CMS’ hired guns to identify and recoup improper Medicare payments. They are paid on a contingency basis…there’s an incentive for them to “find” mistakes.
RACS of Interest to Otolaryngologists Untimed Codes - CPT Codes (excluding modifiers KX, and 59) where the procedure is
not defined by a specific timeframe (untimed codes), the provider should enter a one (1) in the units billed column per date of service.
Example: 92506 - Evaluation of speech, language, voice, communication, and/or auditory processing
Bronchoscopy Services - CPT Codes 31625, 31628 and 31629 should be billed with a maximum number of units of one (1) per patient per date of service (excluding claims with modifier 59) should only be reported with one unit per date of service
Once in a lifetime procedures - By virtue of the description of the CPT code, these codes can be performed only once per patient lifetime.
Example: 31360 - Laryngectomy; total, without radical neck dissection
Pediatric codes exceeding age parameters - Newborn/Pediatric CPT codes being applied/billed for patients which exceed the age limit defined by the CPT code.
Example: 42820- Tonsillectomy and adenoidectomy; under age 12
Resource/Reference List MedlinePlus Interactive Tutorials: Sinus Surgerywww.nlm.nih.gov/medlineplus/tutorials/sinussurgery/htm/index.htm American Rhinologic Societywww.american-rhinologic.org/patientinfo.sinussurgery.phtml Methodologic Assessment of Studies on Endoscopic
Sinus Surgeryhttp://archotol.amaassn.org/cgi/content/short/129/11/1230 American Academy of Otolaryngologywww.entnet.org
Questions?